Melanoma confronts patients and their physicians with unique barriers to treatment and successful outcomes. In this interview with The Life Sciences Report, Dr. Sanjiv Agarwala, chief of medical oncology and hematology at St. Luke’s University Hospital, illuminates some of the new paradigms being developed in the treatment of this deadly skin cancer. Along the way, he spotlights interesting companies working in the field.

The Life Sciences Report: You have been a principal investigator in several different clinical trials exploring skin cancers and their metastatic manifestations. Because of your position at a major teaching institution, do you see mostly advanced-stage or late-stage patients? Are you ever able to see early-stage or treatment-naïve patients?

Sanjiv Agarwala: Being in an academic/teaching institution, it can go either way. Because of my specific interest and expertise in melanoma, and having maintained good working relationships with community oncologists and other physicians in the area, I tend to have patients referred at all stages. Of course, many of them are advanced stage because those patients need me more. But I do get patients with early-stage melanoma, at least for an opinion.

Here at St. Luke’s Cancer Center, when a patient is referred to us, we keep him or her in our database and on our clinic schedule so that we are able to pick up any kind of recurrence or metastases early and intervene in a timely manner, either with treatment or with enrollment in a clinical trial.

TLSR: Were you trained as a hematologist/oncologist?

SA: Yes. Some melanoma specialists come from a dermatology or surgery background, but I was trained in hematology/oncology and, before that, in internal medicine. I’m technically triple-boarded. But as I have developed my career, I have focused on melanoma and the immune system, and that’s pretty much all I do now.

TLSR: Would you briefly compare melanoma versus squamous cell carcinoma versus basal cell carcinoma? What sets melanoma apart? Is it a propensity to metastasize to very tragic areas, such as the brain and liver?

SA: Absolutely. Skin cancer as a whole is extremely common. More than several million patients per year develop skin cancer in the U.S. But melanoma is the least common of all the skin cancers, and is diagnosed in approximately 90,000 (90K) Americans per year. What sets it apart, aside from being the least common, is that it is also, unfortunately, the most dangerous. However, the good news is that if melanomas are picked up early, most of them can be cured—and thank goodness most of them are picked up early.

There are a couple of issues that make melanoma so dangerous. One is that many melanomas don’t look like what you might expect a melanoma to look like, and so they’re hard to identify. The second issue is that melanoma does have a propensity to metastasize. But it’s a tricky cancer that metastasizes even when it’s small, which is somewhat unique. When you think you’ve picked it up early, and you dig deeper, clear the margins, do the sentinel lymph node mapping and so on, you might find that even a small tumor has already metastasized. These factors make melanoma unique.

Another thing is that when melanoma metastasizes to different parts of the body, it tends to metastasize to more dangerous areas—the more tragic areas, as you put it—like the brain and liver. Any organ can be involved, however, and in fact, the most common site of melanoma metastasis is the lung, as well as other subcutaneous tissues, where patients tend to have a better prognosis and survival rate than those with metastases to the liver or the brain.

TLSR: Squamous cell carcinoma occurs much more frequently, and it also metastasizes, doesn’t it?

SA: Yes. But squamous cell metastasizes much less frequently than melanoma. Basal cell carcinomas very rarely metastasize. Still, both these cancers can metastasize and become a clinical problem, and should therefore not be ignored.